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Medical ethics is introduced to students during the first two months of medical school (introductory block) under the subject Introduction to Clinical Medicine (ICM) [24]. During the first two years of the basic science course, medical ethics is incorporated in frequent lectures on topics ranging from professionalism, physician charter, core principles of ethics, duty of care, end of life decisions, human rights, and allocation of resources. Multiple PBL cases with components of ethical principles and one entirely ethics-based PBL session lasting a week are included to encourage the students to reflect on ethical issues and promote self-directed learning [24]. During three years of clinical sciences, students are mandated to maintain a learning log of at least one ethically challenging case per rotation (every eight weeks) in different clinical departments. Students are required to present at least one ethical case in each year of clinical science which is supervised by the attending physician, attended by classmates, and includes extensive post-presentation discussion. The students are also assessed on their knowledge regarding medical ethics during exams via Multiple Choice Questions (MCQs) and Problem Based Questions (PBQs) [24]. During Community Based Learning and Education (CBLE), students are posted at various levels of the health system of Nepal, ranging from working with female community health volunteers to working at a district hospital. One of the specific objectives of CBLE is to describe health care ethics and explore the dilemma of health care ethics in the community. The students are required to submit a learning log on an ethically challenging case faced during such rural postings and maintain a daily diary including such experiences [24, 25].
In most of the cases, participants were able to correctly identify if there had been a breach of ethics in each of the cases; however, they faced difficulty in identifying the main core principle of ethics involved in treating minors (Case 4), end-of-life decisions related to DNR, euthanasia, withdrawal of treatment (Cases 5, 6, 7), treating patients with HIV/AIDS (Case 8), contraception (Case 9) and physician and colleague relationship (Case 10) (Table 7, see Additional file 1). 153554b96e
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